Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

Authority Required (STREAMLINED)

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13100LMPNP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 30 x 0.8 mL unit doses (PI, CMI)	2	2	5	$33.93	$31.60	$31.60
	Available brands
	Systane

Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

Authority Required (STREAMLINED)

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13113EOP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 30 x 0.8 mL unit doses (PI, CMI)	2	2	5	$33.93	$31.60	$31.60
	Available brands
	Systane

Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
5524ROP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 15 mL (PI, CMI)	1	1	5	$15.71	$17.11	$20.56
	Available brands
	Optixa
	Systanea

Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
8676PMPNP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 15 mL (PI, CMI)	1	1	5	$15.71	$17.11	$20.56
	Available brands
	Optixa
	Systanea

Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

Note

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
9219FMP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 15 mL (PI, CMI)	1	1	11	$15.71	$17.11	$20.56
	Available brands
	Optixa
	Systanea